Healthcare Provider Details

I. General information

NPI: 1487393203
Provider Name (Legal Business Name): LEI WILSON DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2022
Last Update Date: 09/29/2025
Certification Date: 09/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7601 W JEFFERSON BLVD
FORT WAYNE IN
46804-4133
US

IV. Provider business mailing address

7601 W JEFFERSON BLVD
FORT WAYNE IN
46804-4133
US

V. Phone/Fax

Practice location:
  • Phone: 260-436-8686
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number5951001444
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: